For physicians who value their self-employed status, the trend toward group practice has been like an unsettling elevator ride. The quick and dramatic descent has left many of them with an uncomfortable feeling in their stomachs.
Large numbers have exited at the ground floor and joined groups or become employed physicians, while a smaller group has climbed the back staircase alone.
"I was in private practice in Santa Barbara, Calif.," says oncologist Michael Henderson, M.D. "Then, in 1982, managed care came to town."
The managed-care groups quickly formed relationships with Santa Barbara's two large clinics. With immediate access to more than 100 physicians, the HMOs had no need for the area's lone practitioners. Henderson consequently was not included in plan contracts.
"So at the age of 41, I went into the Air Force, which enabled me to do the practical work required for a master's degree in public health," Henderson says. He subsequently received his degree and moved to Chicago, where he serves as chief medical officer for CNA, North America's ninth-largest insurance company. If you can't beat 'em, join 'em.
Like Henderson, thousands of other physicians have succumbed to the pressures of managed care, generally becoming either members of larger group practices or employees of healthcare organizations. In fact, according to a recent study conducted by the American Medical Association's Center for Health Policy Research, the proportion of physicians in self-employed solo practices fell to 29% in 1994 from 42% in 1983.
As president of the California Medical Association, Jack Lewin, M.D., is intimately familiar with the shift from solo to group practice. "I have visited every medical school and residency program in the state of California and am not aware of a single student who would go solo," he says.
"Even if they had help from independent practice associations and other resources, these young people don't want to be on call all the time, and they don't want the trouble of running office operations," he explains. "They also enjoy the collegiality of consulting with each other."
Younger physicians, he adds, believe "group practices produce a higher quality of medicine and that they afford better lifestyles. The culture of medicine has changed to meet quality and lifestyle choices."
Insurance plans, CNA's Henderson says, "definitely look more favorably at groups. The main reason for this is that when a group has more than 10 people, it generally has an administrator. Insurance companies would much rather deal with one businessperson than with 10 physicians who may not have much business expertise."
Henderson also points to the dramatic increase in the number of female physicians, noting that more than 50% of admissions to medical school in the past several years have been women. "The way women practice medicine is more compatible to being in a group," he says. Those who are family-oriented "tend to be more collaborative and don't want to put in long, grueling hours."
This point is underscored by Mary Enlow, M.D., an Akron, Ohio-based pediatric ophthalmologist who practices in a group with seven other physicians. "At this point in my life," she says, "I prefer being in a group practice that affords me the luxury of limiting my hours at work. The resulting decrease in my income is offset by the increased time I can spend with my children, who won't be young forever."
Although Lewin maintains that "solo practices will soon be from a bygone era," he notes that certain physicians can still survive well on their own. These include:
Despite the decline in the number of solo practitioners, some authorities believe they will never suffer the fate of the dinosaur. "The statement that solo practices are dying out is almost a cliche," says George Conomikes, chairman and chief executive officer of Conomikes Associates, a Costa Mesa, Calif.-based healthcare consulting firm. "In reality, they can't possibly die out.
"People forget that demographics dictate the number of physicians within localities," he explains. "In some settings, with populations of 5,000 or less, there is only room for one specialist, such as a neurologist or gynecologist. If I'm solo and there's another physician in my specialty 20 miles away, what incentive is there to collaborate -- except perhaps for telephone coverage at night?"
A substantial number of physicians are still practicing medicine on their own, he notes.
A case in point is Dennis Markovitz, M.D., a family practitioner in the Boston area. Before branching off on his own, he worked in several clinics and taught at the University of Massachusetts Medical School. "I wanted a long-term, satisfying arrangement, over which I could have control," Markovitz says of his reason for going solo.
"I was encouraged by Winchester (Mass.) Hospital, with which I'm affiliated, to start a practice," he explains. "The hospital even conducted market research that showed my practice would be a good opportunity. When managed care hit in the '80s, the situation actually improved for me. Suddenly, people needed a primary-care doctor in order to get care."
Markovitz credits much of his success as a solo practitioner to:
"Unlike other hospitals that have secured a primary-care base by employing physicians or buying practices to create physician networks, Winchester has created a strong organization to support its affiliated doctors," he says.
Although he's not ready to partner now, Markovitz says: "Eventually, I would like to have a partner to help handle the workload. I'd especially like help with vacations, since it's hard to leave for two weeks. Patients don't like it."
C. Thompson Hardy, a director at New Health Management, a Cleveland-based
consulting firm that focuses on healthcare provider integration issues, believes two types of markets will continue to support solo physicians. They are markets in which patients can access open-panel physicians who have carved out special niches, and extremely affluent markets in which patients are willing to accept high copayments, premiums and deductibles to retain choice.
Even though he believes solo practitioners will persist, Hardy says most physicians will eventually become members of groups. "I think these groups will become even larger, but that statewide or multistate groups will be less common," he says.
Despite the proliferation of group practices, Conomikes insists physicians can survive, and even thrive, on their own if they:
Although the dizzying elevator ride for physicians is far from over, a smaller number of solo practitioners will manage to survive -- especially in isolated markets. Others will group together, and some will expand their autonomy by moving into management roles.
"Even though physicians are losing their independent practices, I believe they'll assume leadership of the systems that deliver healthcare," Hardy says. "Thus, they'll ultimately be able to retain control in this new environment."
Anne Gallagher is a Hudson, Ohio-based freelance writer who often covers healthcare issues.